Utilization Management LTSS RN

Humana

5d • Remote

About The Position

Become a part of our caring community and help us put health first The Utilization Management (UM) Nurse 2 RN uses clinical nursing skills to support the coordination, documentation and communication of long-term support and services and benefit administration determinations. The UM Nurse work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The UM Nurse 2 work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. You will report to the Manager Utilization Management Nursing. In this role you will: Use clinical knowledge, communication skills, and independent critical thinking skills towards. Interpret criteria and procedures related to Long Term Services and Support authorizations to provide the best treatment, care, or services for members. Coordinate and communicate with providers, members, or other parties to facilitate care and treatment. Understand department and organizational strategy and operating goals, including their linkages to related areas. Follow established guidelines/procedures. Oversee LTSS Utilization Management quality performance, including monitoring LTSS UM performance measures and trends in service authorization compliance points and working with Utilization Manager to develop performance improvement initiatives as appropriate. Attends and advocates on ICT meetings for State Fair Hearings, report monitoring, and review, Attends DMAS training and compliance meetings Routine communication with DMAS, as needed Ensures compliance with state and federal requirements and NCQA standards Use your skills to make an impact

Requirements

• Active Registered Nurse license in the state of Virginia, or obtain a multi-state license bordering contiguous state that participates in the enhanced licensure, (eNLC) without disciplinary action
• Minimum 3 years previous experience in utilization management/ LTSS service authorization
• Minimum two, (2) years prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting or Medicaid Managed Care Organization
• Intermediate to Advanced knowledge using Microsoft Office Word, Excel, PowerPoint, navigating multiple systems and platforms and ability to troubleshoot and resolve basic technical difficulties in a remote environment
• Ability to work independently under general instructions and with a team

Nice To Haves

• Bachelor's or Associate's Degree in Nursing or related field.
• Telephonic case management or in hospital Case Management experience
• Previous experience in discharge planning and/or home health or rehabilitation
• Previous Medicare/Medicaid Managed care experience

Responsibilities

• Use clinical knowledge, communication skills, and independent critical thinking skills towards.
• Interpret criteria and procedures related to Long Term Services and Support authorizations to provide the best treatment, care, or services for members.
• Coordinate and communicate with providers, members, or other parties to facilitate care and treatment.
• Understand department and organizational strategy and operating goals, including their linkages to related areas.
• Follow established guidelines/procedures.
• Oversee LTSS Utilization Management quality performance, including monitoring LTSS UM performance measures and trends in service authorization compliance points and working with Utilization Manager to develop performance improvement initiatives as appropriate.
• Attends and advocates on ICT meetings for State Fair Hearings, report monitoring, and review,
• Attends DMAS training and compliance meetings Routine communication with DMAS, as needed
• Ensures compliance with state and federal requirements and NCQA standards

Benefits

• medical, dental and vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance and many other opportunities

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree